Good Samaritan Home

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an initial care plan on admission to prevent pressure ulcers, failed to implement pressure relieving interventions to prevent the development of pressure ulcers, failed to initiate a pressure ulcer care plan as soon as a pressure ulcer was identified, and failed to obtain a treatment as soon as a pressure ulcer was identified for one resident of four residents (R79) reviewed for pressure ulcers in the sample of 37. These failures resulted in R79 developing two stage two facility acquired pressure ulcers.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to provide a resident with adequate supervision and assistance with footwear to prevent a fall and conduct a thorough investigation with staff interviews after a resident suffered a fall with fracture for one of two residents (R7). This failure resulted in R7's footwear being worn unsafely, and R7 suffering an unwitnessed fall, experiencing swelling and pain in her right wrist and resulting in a distal radius bone fracture requiring cast application.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the dishwashing machine was effectively sanitizing dishes. This failure have the potential to affect all 91 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for two of four residents (R16 and R41) reviewed for abuse in a sample of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to document an appropriate diagnosis and target behaviors to warrant the use of antipsychotic medications, failed to implement behavioral interventions prior to increasing an antipsychotic medication dose, and failed to perform antipsychotic assessments for two of four residents (R10 and R52) reviewed for chemical restraints in the sample of 37.

Inspectors wroteBased on Interview and Record review, the facility failed to report a bruise of unknown origin to the facility's abuse coordinator and the state agency and report an allegation of misappropriation of jewelry to the state agency for two of four residents (R82, R84) reviewed for abuse in the sample of 37.

Inspectors wroteBased on Interview and Record review, the facility failed to complete an abuse investigation for an injury of unknown origin and misappropriation of jewelry for two of four residents (R82, R84) reviewed for abuse in the sample of 37.

Inspectors wroteBased on record review and interview the facility failed to submit a discharge MDS (Minimum Data Set) Assessment after residents were discharged from the facility for two of two residents (R40 and R90) reviewed for Accuracy of Assessments in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a new PASRR (Pre-admission Screen and Resident Review) Level I screening and referral for Level II evaluation following a significant change in condition, including the addition of a psychiatric diagnosis and initiation of psychotropic medication, for one (R10) of three residents reviewed for PASRR compliance in the sample list of 37.

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise and update the comprehensive care plan to reflect significant changes in condition, including the addition of new psychiatric diagnoses, initiation of psychotropic medication, identification of target behaviors, and implementation of non-pharmacological interventions for one (R10) of five residents reviewed in a sample of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store a nebulizer mask and implement a care plan for oxygen/nebulizer use for one of one resident (R1) reviewed for oxygen in the sample of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a multidose vial of lidocaine and multidose insulin pen were labeled with resident identifiers and labeled when opening for two of 19 residents (R1 and R11) reviewed for medication storage and labeling in the sample of 37.

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement standard infection control precautions, failed to apply a gown prior to providing high-contact care for a resident with a wound, and failed to perform hand hygiene during incontinence care for one of one resident reviewed (R12) for Infection control Precautions in the sample of (37).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided timely provider notifications to ensure medical intervention was received with an acute change in condition for one of four residents (R1) reviewed for change in condition in the sample of four. This failure resulted in R1 experiencing a delay in evaluation and treatment while experiencing an acute ischemic stroke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions for 2 (R1 and R3) of 3 residents reviewed for wound care in a total sample of 5. Findings Include:The facility's undated Enhanced Barrier Precautions policy documents: It is the policy of the facility to use Enhanced Barrier Precautions in addition to standard precautions as a method of infection control, requiring the use of gown and gloves in situations of high-contact resident care. Definition: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms. EBP requires gown and glove use during high-contact resident care activities and prevents the spread of infection to and among residents and staff. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide documentation by a physician regarding the basis of a resident's involuntary discharge with indications for why a resident should not return to the facility following hospitalization, what resident needs could not be met at the facility, what the facility's efforts were to meet those needs, and the specific services the receiving facility could provide to meet the needs of the resident which could not be met at the facility for one of three residents (R1) reviewed for involuntary discharge in the sample of four.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident, resident's representative, and the Ombudsman in writing of the reasons for discharge for one of three residents (R1) reviewed for involuntary discharge notice in the sample of four.

Inspectors wroteBased on record review and interview, the facility failed to provide a bed hold notice to a resident and a resident's representative upon transfer to the hospital for one of three residents (R1) reviewed for bed hold notice in the sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use the Heat Stickers to ensure dishes reach the correct/required surface temperature when in the rinse cycle in the dish machine and failed to have staff wash hands with soap and water as required between handling dirty dishes and clean dishes in the dish room. This has the potential to affect all 101 residents living in the facility.

Inspectors wroteBased on record review and interview, the facility failed to report bruises of unknown origin to the State Agency for two of two residents (R35 and R81) reviewed for abuse in the sample of 34.

Inspectors wroteBased on record review and interview, the facility failed to initiate abuse investigations for bruises of unknown origin for two of two residents (R35 and R81) reviewed for abuse in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was transferred safely during a shower to avoid falling for one of five residents (R45) reviewed for falls in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an allegation of potential verbal abuse to the administrator and the State Agency for one of three residents (R2) reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond immediately to a sounding exit door alarm, failed to adequately supervise a known wandering resident (R8), failed to re-assess R8 as high risk for elopement once R8 started to exit seek, failed to develop and implement interventions and plan of care to address R8's exit-seeking behaviors after R8 attempted to exit seek, and failed investigate and report R8's elopement thoroughly for one of three residents (R8) reviewed for elopement in the sample of 41. These failures resulted in R8, a severely cognitively impaired resident with the diagnosis of Dementia, eloping from the facility approximately 70 feet from the facility, falling, and being found on the curb next to the road, after attempting to exit the building earlier that evening on 6-7-23. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident for an underlying condition prior to increasing an anti-psychotic medication, and failed to attempt gradual dose reductions of an anti-psychotic medication for one of four residents (R8) reviewed for anti-psychotic use with the diagnosis of Dementia in the sample of 41.